question_type question_text required page_number option_text option_values
instruction Welcome to this survey. Press Next to begin. 0 1
instruction "The following questions ask about how you have been feeling during the past 30 days. For each
question, please select the option that best describes how often you had this feeling." 0 2
instruction "
Q1: During the past 30 days, about how
often did you feel …
" 0 3
radio … nervous? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio … hopeless? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio … restless or fidgety? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio … so depressed that nothing could cheer you up? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio … that everything was an effort? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio … worthless? 1 3 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
radio "Q2: The last six questions asked about feelings that might have occurred during the past 30
days. Taking them altogether, did these feelings occur more often in the past 30 days
than is usual for you, about the same as usual, or less often than usual? (If you never
have any of these feelings, select “about the same as usual”) " 1 3 A lot, Some
More often than usual
←, A little, About the same as usual, A little , Some
Less often than usual
→, A lot 1,2,3,4,5,6,7
instruction "The next few questions are about how these feelings may have affected you in the past 30 days.
You need not answer these questions if you answered “None of the time” to all of the six
questions about your feelings.
" 0 4
numeric "Q3: During the past 30 days, how many days out of 30 were you totally unable to work or
carry out your normal activities because of these feelings?
(Number of Days)" 0 4
numeric "Q4: Not counting the days you reported in response to Q3, how many days in the past
30 were you able to do only half or less of what you would normally have been able
to do, because of these feelings?
(Number of Days)" 0 4
numeric "Q5: During the past 30 days, how many times did you see a doctor or other health
professional about these feelings?
(Number of Times)" 0 4
radio "Q6: During the past 30 days, how often
have physical health problems been
the main cause of these feelings? " 0 4 All of the time, Most of the time, Some of the time, A little of the time, None of the time 1,2,3,4,5
checkbox Do you have or have you ever been diagnosed with any of the following psychological disorders (check all that apply)? 1 5 ADHD, Alcohol Dependency, Anorexi Nervosa, Anxiety Disorder, Autism/Autism Specturm Disorder, Borderline Personality Disorder, Bulimia, Drug Dependency, Depression, Manic-Depressive (Bilpolar) illness, Obessive Compulsive Disorder, Schizophrenia, Other, None
textfield If you responded “other” to the above question, please describe: 0 5
radio Have you been diagnosed with any neurological disorder (e.g. Alzheimer's, Parkinson's)? 1 5 Yes, No 1, 0
textfield If you responded “yes” to the above question, please describe: 0 5
checkbox Do you have or have you ever been diagnosed with any of the following medical conditions (check all that apply)? 1 5 Type II diabetes, Metabolic Syndrome, High Blood Pressure, Heart Disease, Stroke, Cancer, Sleep Apnea, Other, None
textfield If you responded “other” to the above question, please describe: 0 5
instruction Congratulations for completing this survey! Press finish to continue. 0 6